Jen-Tien Wung

Congenital diaphragmatic hernia: Survival treated with very delayed surgery, spontaneous respiration, and no chest tube

This report suggests that stabilization of the intrauterine to extrauterine transitional circulation combined with a respiratory care strategy that avoids pulmonary overdistension, takes advantage of inherent biological cardiorespiratory mechanics, and very delayed surgery for congenital diaphragmatic hernia results in improved survival and decreases the need for extracorporeal membrane oxygenation (ECMO). This retrospective review of a 10-year experience in which the respiratory care strategy, ECMO availability, and technique of surgical repair remained essentially constant describes the evolution of this method of management of congenital diaphragmatic hernia.

Changing incidence of bronchopulmonary dysplasia

APART FROM RARE AND ISOLATED CASESOfpulmonary fibrosis occurring in very small infants, b ronchopu l monary dysplasia was first noted at the Babies Hospital , New York City, when artificial vent i la t ion for the treatmen t of respiratory distress syndrome was insti tuted. Over the past eight years, the incidence of BPD has fal len as techniques of neona ta l care have been improved and greater experience with artificial vent i la t ion has been gained. The lower incidence occurred despite an increase in survival rate and more frequent use of vent i la tory support on very small infants. We consider that the diagnosis of BPD canno t be m a d e without a history and wi thout a s tudy of sequent ia l films. With the changing techniques of assisted venti lat ion, we now rarely see the typical stages of the disease as described by Northway. In our lnsn tunon , we have seen two types of chronic lung disease in neonates : the first in the smallest in fant with little or no respiratory distress syndrome, and the second in infants surviving severe RD S (Table I). The changing survival rates according to weight group for the period 1972 to 1977 are presented in the Figure. The improved survival rate in very small infants has occurred concurrent ly with changes in bo th obstetr ic pracnce and newborn care. There have been more l iberal indicat ions for cesarean section for p remature b reech deliveries and for the very immatu re infant with fetal distress, as well as an earlier inst i tut ion of CPAP using nasal prongs and an increased use of mechan ica l venti lation for the very immatu re infant with respiratory difficulty. The changing incidence of BPD is presented in Table II. In 1970-1971. the condi t ion was seen in only four of 85 patients with RDS. two of whom were normal at seven months and two years, respectively; two died. A s t h m a and wheezing dur ing the first four years of life were seen in

Randomised controlled trial of thiopental for intubation in neonates

AIMS To determine the effects of premedication with thiopental on heart rate, blood pressure, and oxygen saturation during semi-elective nasotracheal intubation in neonates. METHODS A randomised, placebo controlled, non-blinded study design was used to study 30 neonates (mean birthweight 3.27 kg) requiring semi-elective nasotracheal intubation. The babies were randomly allocated to receive either 6 mg/kg of thiopental (study group) or an equivalent volume of physiological saline (control group) one minute before the start of the procedure. Six infants were intubated primarily and 24 were changed from orotracheal to a nasotracheal tube. The electrocardiogram, arterial pressure wave, and transcutaneous oxygen saturation were recorded continuously 10 minutes before, during, and 20 minutes after intubation. Minute by minute measurements of heart rate, heart rate variability, mean blood pressure (MBP) and transcutaneous oxygen saturation (SpO2) were computed. The differences for all of these between the baseline measurements and those made during and after intubation were determined. Differences in the measurements made in the study and the control groups were compared using Students t test. RESULTS During intubation, heart rate increased to a greater degree (12.0vs −0.5 beats per minute, p < 0.03) and MBP increased to a lesser degree (−2.9 vs4.4 mm Hg; p < 0.002) in the infants who were premedicated with thiopental. After intubation only the changes in MBP differed significantly between the two groups (−3.8vs 4.6 mm Hg; p < 0.001). There were no significant changes in the oxygen saturation between the two groups during or after intubation. The time taken for intubation was significantly shorter in the study group (p < 0.04). CONCLUSIONS The heart rate and blood pressure of infants who are premedicated with thiopental are maintained nearer to baseline values than those of similar infants who receive no premedication. Whether this lessening of the acute drop in the heart rate and increase in blood pressure typically seen during intubation of unmedicated infants is associated with long term advantages to the infants remains to be determined.

Weaning strategy with inhaled nitric oxide treatment in persistent pulmonary hypertension of the newborn

AIM To determine if infants who had become dependent on inhaled nitric oxide treatment could be successfully weaned off it if FIO2 was increased briefly during withdrawal. METHODS Sixteen infants admitted for conditions associated with increased pulmonary vascular resistance responded well to inhaled nitric oxide treatment with a significant increase in PaO2 (maximum inhaled nitric oxide given 25 ppm). Weaning from inhaled nitric oxide in 5 ppm decrements was initiated once the FIO2 requirement was less than 0.5. When patients were stable on 5 ppm of inhaled nitric oxide, the gas was then discontinued. If a patient showed inhaled nitric oxide dependence—that is, oxygen saturation fell by more than 10% or below 85%—inhaled nitric oxide was reinstated at 5 ppm and the patient allowed to stabilise for 30 minutes. At this time, FIO2 was increased by 0.40 and weaning from inhaled nitric oxide was attempted again. RESULTS Nine infants were successfully weaned on the first attempt. The seven infants who failed the initial trial were all successfully weaned following the increase in FIO2. After successful weaning, FIO2 was returned to the pre-weaning level in mean 148(SD 51) minutes and inhaled nitric oxide was never reinstated. CONCLUSION Infants showing inhaled nitric oxide dependency can be successfully weaned by increasing FIO2 transiently.

Preoperative cardiorespiratory trends in infants with congenital diaphragmatic hernia.

The objective of this study was to determine the cardiovascular and pulmonary adaptations of infants with congenital diaphragmatic hernia (CDH) from birth until delayed surgery through the use of continuous monitoring. Continuous cardiovascular (HR, heart rate variability [HR-SD], BP, blood pressure variability [BP-SD], and oxygen saturation) and ventilatory (minute volume, airway pressure, and effective compliance) measurements were made on-line, using a computerized whole-body plethysmograph-incubator (Vital-trends, VT1000), in nine ventilated infants with CDH. Data collection commenced at birth and continued until surgery. Minute mean values for each variable were recorded. Hourly means were computed from the minute means, averaged across infants each hour over the first 50 hours of life, and regressed against postnatal age. Results showed a significant increase in BP (P < .01), BP-SD (P < .05), HR-SD (P < .04), and pH (P < .02) versus postnatal age, and a decrease in PaCO2 (P < .04), FIO2 (P < .001), Alveolar-arterial oxygen gradient (P < .003), and oxygenation index (P < .002). Infants with CDH show cardiopulmonary trends over the first 2 days of life that are qualitatively similar to those of normal newborn infants. Deviation from these idealized patterns may identify an infant who is not responding satisfactorily to the given therapy and who may require alternative treatment modalities.

Factors Affecting the Weaning from Nasal CPAP in Preterm Neonates

Objective. Identification of the weight and postmenstrual age (PMA) at successful weaning of NCPAP in preterm neonates and the factors influencing the successful wean. Study Design. Retrospective review of 454 neonates ≤32 weeks of gestational age (GA) who were placed on NCPAP and successfully weaned to room air was performed. Results. Neonates had a mean birth weight (BW) of 1357 ± 392 grams with a mean GA of 29.3 ± 2.2 weeks. Neonates were weaned off NCPAP at mean weight of 1611 ± 432 grams and mean PMA of 32.9 ± 2.4 weeks. Univariate analysis showed that chorioamnionitis, intubation, surfactant use, PDA, sepsis/NEC, anemia, apnea, GER and IVH were significantly associated with the time to NCPAP wean. On multivariate analysis, among neonates that were intubated, BW was the only significant factor (P < 0.001) that was inversely related to time to successful NCPAP wean. Amongst non-intubated neonates, along with BW (P < 0.01), chorioamnionitis (P < 0.01), anemia (P < 0.0001), and GER (P < 0.02) played a significant role in weaning from NCPAP. Conclusion. Neonates were weaned off NCPAP at mean weight of 1611 ± 432 grams and mean PMA of 32.9 ± 2.4 weeks. BW significantly affects weaning among intubated and non-intubated neonates, though in neonates who were never intubated chorioamnionitis, anemia and GER also significantly affected the duration on NCPAP.

Inhaled Nitric Oxide Response in Premature Infants with Persistent Pulmonary Hypertension 1623

Background: Persistent pulmonary hypertension (PPHN) is a significant cause of neonatal morbidity and mortality frequently associated with diseases of term and near-term infants. In recent years, it has also been recognized in preterm infants with respiratory distress syndrome (RDS). We report our experience of inhaled nitric oxide (INO) use in critically ill premature infants with PPHN.

INHALED NITRIC OXIDE (INO) DECREASES THE NEED FOR EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) IN NEONATES WITH MECONIUM ASPIRATION SYNDROME (MAS). 1926

OBJECTIVE: To compare the need for ECMO in neonates with persistent pulmonary hypertension (PPHN) associated with MAS before (Group-I) and after (Group-II) INO became available.

LONG TERM USE OF LARYNGEAL MASK AIRWAY (LMA) IN NEONATES WITH ROBIN SEQUENCE.2121

Neonates with Robin sequence (micrognathia, cleft palate and glossoptosis) frequently have severe upper airway obstruction. Depending on the range of severity, treatment modalities include positioning the infants face down, inserting an oropharyngeal airway, endotracheal intubation or long term tracheostomy. Many of these infants may require intubation due to inadequacy of nasal CPAP in presence of a cleft palate. Intubation of these neonates may also be challenging and sometimes impossible. Long term tracheostomy may carry the risks of pneumonia, and impairment of speech development and pharyngeal growth. The use of a LMA (size #1) for anesthesia and in the aid for difficult intubation has been described. We present our experience with three cases of Robin sequence who were treated with long term use of a LMA to relieve upper airway obstruction and deliver CPAP.

WEANING STRATEGY WITH INHALED NITRIC OXIDE THERAPY IN PERSISTENT PULMONARY HYPERTENSION OF THE NEWBORN. 1928

BACKGROUND: A significant number of infants who respond favorably to inhaled nitric oxide (INO) therapy prove difficult to wean off INO. This INO dependence necessitates prolonged use of INO or, on occasion, the use of alternative treatments, such as extracorporeal membrane oxygenation (ECMO). We observed that infants who appeared to be INO dependent could, in fact, be successfully weaned if the FIO2 was increased briefly during the withdrawal of INO therapy.